In each of his three operating rooms, Dr. Mark Craig keeps the glass vials in the same place, in the same top drawer, all within arm’s length of where he performs oral surgery that requires some type of sedation. These are the code meds, easily accessible should a patient go into cardiac arrest and require resuscitation. He also has on hand drugs to reverse the effects of narcotics, equipment to reestablish a patient’s airway if it becomes obstructed, extra fluids. It’s all there if he needs it, all the time.
Craig and his team watch the patient’s vitals using a cream-colored monitor housed in a shelf next to all those drugs. There’s central gas in that shelf, too, and demand valves to ventilate patients who stop breathing. The same goes for the other two rooms. Craig, a board-certified oral and maxillofacial surgeon, made this uniformity a priority at his McKinney practice. If there’s an emergency, he wants as few variables as possible, and so his rooms are, for the most part, replicas of each other, even more homogeneous than the two-story suburban homes that surround his building.
“Everything is in the room,” he says. “Redundancy is the key to salvation.”
There is a battle brewing over how dental anesthesia is practiced in Texas. One side has argued for the status quo. Craig, a former president of the Texas Society for Oral and Maxillofacial Surgeons, is emblematic of the side seeking more oversight from the Texas State Board of Dental Examiners. The Sunset Advisory Commission appears to agree with him. That’s the state agency that audits and recommends changes of other state agencies. It recently published an interim report recommending that the dental board reevaluate how it oversees the process of anesthesia permitting. The dental board does not mandate inspections of general dentists with anesthesia permits; 39 states require those inspections, and three others allow it. The board also suspended its inspection of dental and oral surgery practices in 2014, although it plans to resume it this year.
The Sunset report recommends two changes to how anesthesia is administered: that practices be inspected and that sedation providers have a written emergency plan.
Too, the dental board does not vet the curriculum for the continuing education courses that dentists can attend to receive the permits necessary to perform moderate anesthesia. There is no verification that a dentist providing sedation has an emergency plan in place should something go wrong, nor is there state control over whether assistants are present during the procedure. And, for that matter, the dental board hasn’t established a mechanism to regulate or accredit the thousands of dental assistants that practice in Texas.
And so in June, at a four-hour public hearing on the Sunset Advisory Commission’s audit of the dental board, assistant director Joe Walraven led off by saying: “For a relatively small agency, the dental board has had more than its share of controversy and turmoil. The staff report paints a picture of a board perhaps more motivated by business interests than a demonstrated concern for public safety, an agency plagued by high staff turnover, and an organization in need of greater strategic vision in order to see emerging problems and the leadership to address them.”
State Senator Robert Nichols (R-Jacksonville) put it frankly: “I’m just really a lot more concerned with who has their hand in my mouth these days than I was before I read the report.”
The dental board declined an interview for this story, citing the ongoing Sunset review. A spokesperson also failed to respond to a list of questions sent via email. But the dental board has had a spotlight on it since a 2015 Dallas Morning News investigation of state records found that 85 dental patients had died since 2010, nearly two each month. The Sunset report took a look at 100 anesthesia complaints since 2012 and found 41 deaths, 13 of which it linked to lapses in patient care. The data that the state keeps essentially stops at outcomes, offering no details on the providers, their training, or their permitting. But, as state Senator Charles Schwertner (R-Georgetown) notes, over the last four years there’s been a fourfold increase in dental anesthesia-related deaths.
According to Sunset, there are 3,075 active oral permits for moderate anesthesia, known as Level 2; 1,668 intravenous anesthesia permits for moderate sedation, known as Level 3; and 558 permits for general anesthesia or deep sedation, known as Level 4, generally held by oral surgeons or dentists who attend a three-year anesthesiology program. (The American Dental Association defines moderate sedation as “a drug-induced depression of consciousness during which patients respond purposefully to verbal commands.”) The vast majority of these permit holders, particularly those who can practice moderate sedation under Level 2 and 3 permits, are dentists. And by law, under the recommendations passed down by the American Dental Association, to perform moderate oral sedation, a dentist needs 24 hours of instruction and 10 practice cases, only three of which need to be actual patients (the rest can be done with dummies or observing other dentists); to perform moderate sedation through an IV, they need 60 hours of instruction and 20 cases.
But that’s it. The oversight stops there. No state accrediting body, no curriculum checks. Just get the necessary hours and cases, fill out an application, pay a fee, get the permit.
“I absolutely believe that is a major problem,” says Dr. Ken Reed, a dentist anesthesiologist based in Oregon and the president of the American Dental Society of Anesthesiology. “You can find parenteral moderate sedation [IV sedation] courses for dentists that are run by non-dentists and even run by non-physicians. In some cases, these course directors cannot legally order drugs nor provide sedation in a dental office, yet they are teaching dentists to do so.”
Then there is the matter of where these sedations take place. In 2011, the dental board passed a “portability” rule allowing dentists and dentist anesthesiologists to make deals with a general dentist to use his or her building to provide sedation for things like wisdom teeth removal. Unlike Craig, intimately familiar with his three operating rooms in McKinney, these itinerants travel from office to office.
Perhaps Texas’ foremost itinerant is Dr. David Roberts, a general dentist based in Dallas who provides services throughout the region. Roberts testified before the Sunset hearing in June that he practices in 75 dental offices and has treated more than 25,000 patients as an itinerant dentist throughout his 30-year career. Before declining to be interviewed for this story, Roberts told me that he believes healthcare decisions should be “between the doctor and his patient,” not something regulated in Austin. He said the itinerant model allows patients to receive surgical procedures where they get their teeth cleaned, with “the same office lady, the same ambience, the same parking spot.”
The lax regulations from the dental board and roaming models like Roberts’ have fueled consternation among oral surgeons, who raise concerns over safety. The dentists scoff at that complaint. Roberts, who has never been disciplined by the board, testified that every death he’s encountered was due to “gross judgment, negligence,” and data doesn’t note whether the practitioners were itinerant or fixed, what specialty they are, whether they had an emergency plan, or whether the office where the death occurred was equipped for the procedure.
“Is the training sufficient for the delivery of moderate anesthesia?” Senator Schwertner asked Roberts during the hearing.
“I do think they are sufficient,” he responded. “And the reason I think they’re sufficient is that I do not know in my 30 years that I’ve ever heard of a death where the guidelines were followed.”
That argument doesn’t hold water for Schwertner or for Sunset. One of the cases mentioned in the Sunset report concerned a man who stopped breathing as he lay in a dental chair, in deep sedation. An itinerant dentist had accidentally left his resuscitation equipment in his car and ordered an assistant to retrieve it. The anesthesia complicated the patient’s heart disease, which caused his death. The dentist administering the anesthesia was suspended pending 320 hours of continuing education and an office inspection. That case encapsulates another problem, that the dental board has failed to identify high-risk patients—the young, the old, the sick—and institute guidelines for how or where these patients are placed under sedation. Patient deaths like that and dental board inaction have drawn the ire of elected officials.
The Sunset report recommends two changes to how anesthesia is adminstered: that practices be inspected and that sedation providers have a written emergency plan. But Schwertner plans to go further. As this story went to press, in late July, he was preparing to present his own recommendations to Sunset ahead of an August 24 vote. He wants regulation of the curriculum in the anesthesia courses, an investigation of the proficiency of the permit holders, maintenance of better data regarding adverse outcomes, and increased scrutiny of dentists who practice itinerantly.
“I think it’s very important for the health, safety, and welfare for Texans receiving dental care that proper dental anesthesia rules are implemented,” Schwertner says. “If the dental board isn’t going to do it through rule-making, I feel it’s incumbent upon the Legislature to do it through statutory law.”